ED Risk Stratification of Chest Pain
Search Strategy: You conduct a PUBMED search using “Clinical Queries” and select “Clinical Prediction Guide” with the search term “chest pain” and the option for a narrow, specific search. This strategy yields 157 citations including the Vancouver Rule (#12), London-St. Thomas Rule (# 15), TIMI (#69), and Goldman’s criteria (#130). You note with interest that multiple other decision aids exist including one for patients already admitted with ACS (GRACE model), computerized ECG tools (ACI-TIPI), women, young adults, and cocaine-induced chest pain. Since your patient is neither female, young (< 40), or cocaine-induced, since your ECG machine doesn’t have ACI-TIPI installed, and since you’ve not yet decided whether the patient is being admitted or whether he is suffering from ACS, you select those papers most suited to all-comers with chest pain.
The Accreditation Council for Graduate Medical Education (ACGME) is continuing an emphasis on educational outcomes in residency education through multiple core competencies. As such, they have encouraged EM Program Directors to select a single core competency each year for direct standardized observation. Your program has selected “chest pain” as the initial problem-based core competency. You vow to set the curve on this core competency evaluation and turn to the medical literature to do so.
Your first chest pain patient is a 40-year old African-American male with 2-hours of unremitting, non-exertional, non-pleuritic right-sided chest pain which began while he was watching Magnum PI at 11 AM. He notes a history of hypertension, but denies any other medical history. He does not smoke cigarettes, denies illicit substance abuse, and has no knowledge of any family history of coronary artery disease. Whether or not you want it, Triage has obtained an ECG (normal by your interpretation) during the patient’s 1.5 hour ED waiting room stay. He has had no palliative measures initiated. Your attending physician, blue chest pain SDOT in hand, eagerly watches your data gathering before verbally exploring your differential diagnosis and management plans.
Having thus far witnessed a heterogeneous, mostly anecdotal approach to chest pain evaluation and management among the Emergency Medicine physicians with whom you have worked during your training, you hesitate. Does a validated, ED-accessible tool exist with which to systematically evaluate chest pain patients? You request a 5-minute delay to evaluate the evidence.
Population: ED patients presenting with chest pain
Intervention: Systematic risk assessment
Comparison: Non-systematic (gestalt) risk assessment
Outcome: Short-term cardiac mortality, long-term mortality, cardiovascular functional status and co-morbidity
First years: Ruling Out Acute Myocardial Infarction: A Prospective Multicenter Validation of a 12-hour Strategy for Patients at Low Risk, NEJM 1991; 324: 1239-1246.
Second years: A Simple Score for Predicting Coronary Artery Disease in Patients with Chest Pain. Quality J Med 2005; 98: 803-811.
Third years: A Clinical Prediction Rule for Early Discharge of Patients with Chest Pain. Annals EM 2006; 47: 1-10.
Fourth years: The TIMI Risk Score for Unstable Angina/Non-ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making. JAMA 2000; 284: 835-842.
Article 1: Ruling Out Acute Myocardial Infarction: A Prospective Multicenter Validation of a 12-hour Strategy for Patients at Low Risk; NEJM 1991; 324: 1239-1246.
Article 2: A Simple Score for Predicting Coronary Artery Disease in Patients with Chest Pain, Q J Med 2005; 98: 803-811
Article 3: A Clinical Prediction Rule for Early Discharge of Patients with Chest Pain, Ann EM 2006; 47: 1-10
Article 4: The TIMI Risk Score for Unstable Angina/Non-ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making; JAMA 2000; 284: 835-842
Chest pain represents 5-8% of all ED visits in the US with 30% of monetary losses in EM litigation related to missed MI. At BJH in 2005 among those with a chief complaint of chest pain the incidence of AMI (both STEMI and NSTEMI) was 6.1%, while the incidence of USA was 4.6%. Multiple decision-aids have been developed over the last 25 years to assist clinicians in appropriate, cost-effective risk stratification of chest pain patients. In this Journal Club, we’ve highlighted one historical decision aid (Goldman), one highly utilized tool (TIMI) and two new CDR’s (Vancouver and London Rules). Of these, TIMI was recently validated in EM populations (see PGY-IV Answer KEY) but may be most appropriate for stratification of moderate to high-risk chest pain patients to determine where you are going to admit and what treatment modalities might be most effective. On the other hand, the new Vancouver Chest Pain Rule, if validated, may be more appropriate for low risk patients who you are contemplating discharging home from the ED.